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Sudden Death From Myocarditis in Young Athletes
Letters Entamoeba
polecki
dazole therapy. Interestingly, the symptoms in that patient could not be attributable to the Entamoeba infection but rather were attributed to an associated salmonellosis.
Infection in France
We read with considerable interest the report by Gay and coauthors on Entamoeba polecki infection in South east Asian refugees, which was published in the August issue of the Proceedings (pages 523 to 530). We would like to correct an erroneous statement that appeared in the discussion of that article. The authors stated that E. polecki was identified for the first time in Strasbourg, France, in 1982.1 In 1980, we2 published a case of E. polecki infection in a 53-year-old Briton woman who had never left France. She lived on a farm with pigs and was the only person in the family to experience such an infection. Cysts definitely disappeared from the feces after administration of two regimens of metronidazole (250 mg four times a day for 10 days and 500 mg four times a day for 14 days); this outcome supports the results of Gay and colleagues. In rare cases, E. polecki may be a pathogen for humans, attributable to domestic animals. We regret that our case was not reported in the references of the Proceedings article by Gay and associates.
J. Douglas Gay, M.D. Thomas L. Abell, M.D. John H. Thompson, Jr., Ph.D. Vacchira Loth
Hypoglycemia and Home Parenteral Nutrition
J. M. Boles, M.D. O. Masure, M.D. Centre Hospitalier Regional et Universitaire Brest, France
REFERENCES
1. Chaker E, Kremer M, Kien TT: Quatorze cas d'Entamoeba polecki chez des refugies du Sud-Est asiatique: remarques sur l'aspect morphologique du parasite. Bull Soc Pathol Exot Filiales 75:484-490, 1982 2. Masure O, Boles JM, Bayon AM, Leuzinger D, Bergeret G: Infestation a Entamoeba polecki chez l'homme: revue de la litterature a propos d'une observation brestoise. Bull Soc Pathol Exot Filiales 73:451-457, 1980
The article by Nelson on hypoglycemia in the December 1985 issue of the Proceedings (pages 844 through 850) omits an important cause of severe hypoglycemia. Severe symptomatic hypoglycemia will occur uniformly in patients on home parenteral nutrition if they abruptly terminate their nightly nutrient infusion, which contains high concentrations of glucose. This problem can be obviated by teaching the patient on home parenteral nutrition to slow the infusion to onefourth the usual rate for 15 to 45 minutes before termination of the procedure. (A large individual varia tion exists in this tapering procedure.) Unpublished data of Dr. John Ensinck in the Department of Endocri nology at the University of Washington reveal a 5-fold to 10-fold increase in insulin levels during the nightly infusion of nutrients in these patients. Beiding H. Scribner, M.D. Department of Medicine University of Washington Seattle, Washington
Sudden Death From Myocarditis in Young Athletes The authors reply We appreciated the letter from Drs. Boles and Masure and apologize for not citing the case report of Entamoeba polecki infection that they had published in the French medical literature. That report emphasizes the importance of contact with pigs in the transmission of the parasite and confirms the effectiveness of metroni Mayo Clin Proc 61:226-227, 1986
In his Cardiovascular Clinics contribution in the De cember 1985 issue of the Proceedings (pages 867 through 873), Driscoll makes an important contribution to the understanding of the importance and conduct of preparticipation sports evaluations in children and adolescents. In his review of the cardiovascular causes of sudden nontraumatic death in this age group, how ever, he omits myocarditis, which may be the most 226
Mayo Clin Proc, March 1986, Vol 61
common cardiovascular cause of this unfortunate event. Several studies h a v e noted the frequency a n d i m p o r t a n c e of myocarditis in sudden a n d unexpected n a t u r a l d e a t h in childhood a n d adolescence. 1 " 4 Clinicians m a y be u n a w a r e of this a b r u p t manifesta tion of myocarditis, because most of these p a t i e n t s h a v e nonspecific prodromes a n d are not referred to a cardiol ogist. These y o u n g p a t i e n t s usually die in their own community, a n d their lesions are detected a t autopsies supervised by coroners or medical examiners. 1 T h e diagnosis of myocarditis would be unlikely during a n e x a m i n a t i o n before participation in sports. T h e associa tion of viral s y m p t o m s with sudden unexpected d e a t h in y o u n g athletes, however, suggests t h a t subclinical viral myocardial infection m a y occur a n d t h a t strenuous physical activity m i g h t be unwise during a n d for some period after acute viral illnesses. 5 , 6 Also, some medica tions with cardioactive properties, such a s decongest a n t s a n d bronchodilators, m a y h a v e adverse effects during systemic viral infections a n d m a y generate lifet h r e a t e n i n g d y s r h y t h m i a s . T h e incidence of subclinical myocarditis h a s not been adequately investigated, a n d further study of this condition is needed to prevent sudden d e a t h from myocarditis. Daniel R. Neuspiel, M.D., M.P.H. Division of Pediatric a n d P e r i n a t a l Epidemiology Rose F. Kennedy Center Albert Einstein College of Medicine Bronx, New York
LETTERS
227
REFERENCES 1. Neuspiel DR, Kuller LH: Sudden and unexpected natural death in childhood and adolescence. JAMA 254:1321-1325, 1985 2. Wentworth P, Jentz LA, Croal AE: Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis. Can Med Assoc J 120:676-680, 1979 3. Molander N: Sudden natural death in later childhood and adolescence. Arch Dis Child 57:572-576, 1982 4. Topaz O, Edwards JE: Pathologic features of sudden death in children, adolescents, and young adults. Chest 87:476482, 1985 5. Kocnar K, Rous J: Preventive approach to sudden cardiac deaths at sports performance. Br J Sports Med 7:166-167, 1973 6. Tunstall-Pedoe D: Exercise and sudden death. Br J Sports Med 12:215-219, 1979
Dr. Driscoll replies I appreciate Dr. Neuspiel's letter a n d concur with his addition of myocarditis to the list of causes of sudden unexpected d e a t h a m o n g y o u n g athletes. His comments should alert clinicians to the possible occurrence of subclinical myocarditis in this age group. David J. Driscoll, M.D.
The Editor welcomes letters a n d comments, particularly p e r t a i n i n g to recently published articles in the Proceedings. A letter should be no longer t h a n 500 words a n d contain no more t h a n five references. T h e letter should be signed. It is a s s u m e d t h a t appropriate letters m a y be published, a t the discretion of the Editor, unless the writer indicates otherwise. Receipt of letters will not be acknowledged. T h e Editor reserves the r i g h t to edit letters in accord with Proceedings style a n d to abridge t h e m if necessary.
polecki
dazole therapy. Interestingly, the symptoms in that patient could not be attributable to the Entamoeba infection but rather were attributed to an associated salmonellosis.
Infection in France
We read with considerable interest the report by Gay and coauthors on Entamoeba polecki infection in South east Asian refugees, which was published in the August issue of the Proceedings (pages 523 to 530). We would like to correct an erroneous statement that appeared in the discussion of that article. The authors stated that E. polecki was identified for the first time in Strasbourg, France, in 1982.1 In 1980, we2 published a case of E. polecki infection in a 53-year-old Briton woman who had never left France. She lived on a farm with pigs and was the only person in the family to experience such an infection. Cysts definitely disappeared from the feces after administration of two regimens of metronidazole (250 mg four times a day for 10 days and 500 mg four times a day for 14 days); this outcome supports the results of Gay and colleagues. In rare cases, E. polecki may be a pathogen for humans, attributable to domestic animals. We regret that our case was not reported in the references of the Proceedings article by Gay and associates.
J. Douglas Gay, M.D. Thomas L. Abell, M.D. John H. Thompson, Jr., Ph.D. Vacchira Loth
Hypoglycemia and Home Parenteral Nutrition
J. M. Boles, M.D. O. Masure, M.D. Centre Hospitalier Regional et Universitaire Brest, France
REFERENCES
1. Chaker E, Kremer M, Kien TT: Quatorze cas d'Entamoeba polecki chez des refugies du Sud-Est asiatique: remarques sur l'aspect morphologique du parasite. Bull Soc Pathol Exot Filiales 75:484-490, 1982 2. Masure O, Boles JM, Bayon AM, Leuzinger D, Bergeret G: Infestation a Entamoeba polecki chez l'homme: revue de la litterature a propos d'une observation brestoise. Bull Soc Pathol Exot Filiales 73:451-457, 1980
The article by Nelson on hypoglycemia in the December 1985 issue of the Proceedings (pages 844 through 850) omits an important cause of severe hypoglycemia. Severe symptomatic hypoglycemia will occur uniformly in patients on home parenteral nutrition if they abruptly terminate their nightly nutrient infusion, which contains high concentrations of glucose. This problem can be obviated by teaching the patient on home parenteral nutrition to slow the infusion to onefourth the usual rate for 15 to 45 minutes before termination of the procedure. (A large individual varia tion exists in this tapering procedure.) Unpublished data of Dr. John Ensinck in the Department of Endocri nology at the University of Washington reveal a 5-fold to 10-fold increase in insulin levels during the nightly infusion of nutrients in these patients. Beiding H. Scribner, M.D. Department of Medicine University of Washington Seattle, Washington
Sudden Death From Myocarditis in Young Athletes The authors reply We appreciated the letter from Drs. Boles and Masure and apologize for not citing the case report of Entamoeba polecki infection that they had published in the French medical literature. That report emphasizes the importance of contact with pigs in the transmission of the parasite and confirms the effectiveness of metroni Mayo Clin Proc 61:226-227, 1986
In his Cardiovascular Clinics contribution in the De cember 1985 issue of the Proceedings (pages 867 through 873), Driscoll makes an important contribution to the understanding of the importance and conduct of preparticipation sports evaluations in children and adolescents. In his review of the cardiovascular causes of sudden nontraumatic death in this age group, how ever, he omits myocarditis, which may be the most 226
Mayo Clin Proc, March 1986, Vol 61
common cardiovascular cause of this unfortunate event. Several studies h a v e noted the frequency a n d i m p o r t a n c e of myocarditis in sudden a n d unexpected n a t u r a l d e a t h in childhood a n d adolescence. 1 " 4 Clinicians m a y be u n a w a r e of this a b r u p t manifesta tion of myocarditis, because most of these p a t i e n t s h a v e nonspecific prodromes a n d are not referred to a cardiol ogist. These y o u n g p a t i e n t s usually die in their own community, a n d their lesions are detected a t autopsies supervised by coroners or medical examiners. 1 T h e diagnosis of myocarditis would be unlikely during a n e x a m i n a t i o n before participation in sports. T h e associa tion of viral s y m p t o m s with sudden unexpected d e a t h in y o u n g athletes, however, suggests t h a t subclinical viral myocardial infection m a y occur a n d t h a t strenuous physical activity m i g h t be unwise during a n d for some period after acute viral illnesses. 5 , 6 Also, some medica tions with cardioactive properties, such a s decongest a n t s a n d bronchodilators, m a y h a v e adverse effects during systemic viral infections a n d m a y generate lifet h r e a t e n i n g d y s r h y t h m i a s . T h e incidence of subclinical myocarditis h a s not been adequately investigated, a n d further study of this condition is needed to prevent sudden d e a t h from myocarditis. Daniel R. Neuspiel, M.D., M.P.H. Division of Pediatric a n d P e r i n a t a l Epidemiology Rose F. Kennedy Center Albert Einstein College of Medicine Bronx, New York
LETTERS
227
REFERENCES 1. Neuspiel DR, Kuller LH: Sudden and unexpected natural death in childhood and adolescence. JAMA 254:1321-1325, 1985 2. Wentworth P, Jentz LA, Croal AE: Analysis of sudden unexpected death in southern Ontario, with emphasis on myocarditis. Can Med Assoc J 120:676-680, 1979 3. Molander N: Sudden natural death in later childhood and adolescence. Arch Dis Child 57:572-576, 1982 4. Topaz O, Edwards JE: Pathologic features of sudden death in children, adolescents, and young adults. Chest 87:476482, 1985 5. Kocnar K, Rous J: Preventive approach to sudden cardiac deaths at sports performance. Br J Sports Med 7:166-167, 1973 6. Tunstall-Pedoe D: Exercise and sudden death. Br J Sports Med 12:215-219, 1979
Dr. Driscoll replies I appreciate Dr. Neuspiel's letter a n d concur with his addition of myocarditis to the list of causes of sudden unexpected d e a t h a m o n g y o u n g athletes. His comments should alert clinicians to the possible occurrence of subclinical myocarditis in this age group. David J. Driscoll, M.D.
The Editor welcomes letters a n d comments, particularly p e r t a i n i n g to recently published articles in the Proceedings. A letter should be no longer t h a n 500 words a n d contain no more t h a n five references. T h e letter should be signed. It is a s s u m e d t h a t appropriate letters m a y be published, a t the discretion of the Editor, unless the writer indicates otherwise. Receipt of letters will not be acknowledged. T h e Editor reserves the r i g h t to edit letters in accord with Proceedings style a n d to abridge t h e m if necessary.